The 2020s
100 Years of Texas Nursing Magazine
A Pandemic Changes Everything
Shanna Howard and Kanaka Sathasivan, MPH
Texas Nurses Association Staff
Texas Nursing, Issue 2, 2020
FOR NURSES who have been practicing over the last four decades, the COVID-19 pandemic has been a stark parallel to the AIDS crisis of the late ‘80s, right down to seeing Dr. Anthony Fauci back on the news. From the zoonotic origins of the viruses, to the severe and rapid decline seen in people with AIDS or COVID-19, to how quickly both HIV and SARS-CoV-2 have spread with travel—nurses may be facing a new virus, but they are reliving the same challenges.
TRANSMISSION AND SPREAD
The spread of both HIV and SARS-CoV-2 started with a lack of knowledge—especially upon their discovery—although communication, science, and technology move much faster now. While the novel coronavirus has been sequenced since January, more strains are found on a weekly basis but without clear connections to the severity of the illness. At the time of publication, we still do not know how many United States residents have gotten the virus and have inaccurate mortality and transmission rates.
“You know HIV has really changed medicine,” says retired nurse educator Esther Wooten, BSN, MS. “You don’t sign an operative permit without being reminded about HIV. And if you get a transfusion, they’re exculpating themselves that it won’t be their fault if you catch HIV. It’s still out there, and that’s how prominent it became.”
Nurses today have information at their fingertips and the ease of communications means quick dissemination of knowledge. In contrast, the discovery of AIDS, and subsequently HIV, took several years.
Maribel M. Marquez-Bhojani, MSHSA, BSN, RN, NPD-BC, was the head nurse in the mid-80s at Bird S. Coler Memorial Hospital in New York City. She recalls being desperate for knowledge at the time. “I was wanting to learn, and I had all this literature that I got from the infectious disease faculty.” She read articles during her subway commute but remembers the fear people showed. “The subway was so jam-packed, and you would see slowly people start getting away from me.”
While many illnesses start with confusion and anxiety, HIV and COVID-19 face a unique challenge that ultimately hinders public health: stigma.
STIGMA AND FEAR
“Stigma is very big with HIV because of the transmission: bloodborne transmission with sexual activity or IV drug use,” says C. Andrew Martin, DNP, MS, RN, CNE, ACRN, CHPN, an HIV/AIDS certified registered nurse and doctorate of nursing practice program director and associate professor at Regis College.
That stigma led to people underestimating their own risk. “Everybody wanted to say it was just among homosexuals and that would be the only population affected,” says Wooten, “but all sexually active individuals were at risk.”
“COVID does not really have the stigma that HIV does, because it’s not really driven by a specific activity other than social contact,” says Martin. “But now we’re beginning to see social contact as being a negative thing. We crave human connection, but now there’s a stigma attached to having human connection.”
In the ‘80s, nurses played a key role in caring for those with the illness, and just like now, sometimes nurses were the only human connection the patients had near the end of their lives. “Even affluent patients [with HIV] were left on their own, and we became their family members, their friends, because they were disowned,” says Marquez-Bhojani. In addition to being disowned, many patients also lost their significant others to the illness. “They had no support system.”
Even today, people living with HIV still face stigma. “We never got over the stigma of it,” says Wooten. “Let’s not let COVID-19 be the same.”
Like Marquez-Bhojani’s treatment on the subway, nurses were also stigmatized—both then and now. Daily, nurses report being harassed in grocery stores and coffee shops. While we have come a long way from the ‘80s, we still don’t know the full effects of any stigma that might come to be associated with COVID-19.
Like HIV fueling homophobia, COVID-19 has fueled discrimination against Asian-Americans, nurses and doctors among them. Both diseases also have a serious impact on other minority communities.
RACE AND DISPARITIES
Like HIV fueling homophobia, COVID-19 has fueled discrimination against Asian-Americans, nurses and doctors among them. Both diseases also have a serious impact on other minority communities.
“HIV and AIDS started out as a gay, white male disease,” says Martin. “But now four decades later, it’s predominantly in the African-American and Hispanic communities.”
While ethnicity and race do not make someone more susceptible to either SARS-CoV-2 or HIV, the disproportionate impact reflects the outside factors that influence health, including access to care.
“We need to be looking at it as a reflection of our public health system and how the United States deals with the social determinants of health,” says Martin. “Are we seeing a higher incidence of both diseases where there is poverty, unemployment, lack of insurance, food scarcity, and homelessness?”
At the time of publication, 14 states had reported ethnic disparities in deaths compared to their population demographics.1 In Mississippi, for example, African-Americans comprised 72% of COVID-19 deaths, although only 38% of the state identifies as African-American.
PROGRESS AND PREDICTIONS
As we move into a future where SARS-CoV-2 and COVID-19 may be as endemic as HIV and AIDS, we look to the past for guidance on issues we could soon face.
“Confidentiality has been huge with HIV over the last four decades,” says Martin. “In the early years of the epidemic, you would not share your HIV status for fear of losing your job.” Wooten remembers how people were labeled by their status: “At first when someone was admitted, you didn’t put the diagnoses down. You didn’t let the insurance company know.”
Confidentiality also complicates contact tracing. Martin says, “In the news I see a push for tracking as a way to prevent COVID-19 transmission. But is there a confidentiality issue with being infected with COVID? Is it similar to HIV infection?”
Another parallel and hope for the future appears in the value of testing. “With HIV, the federal government has set a goal for people to know their status,” says Martin. “They’ve recently come out with home tests. We’re also seeing this push with COVID testing, drive-through testing, or whether a home test will be available.”
However, Martin stresses that follow-up to testing with a health professional is key. In the HIV field, that means helping people with the virus receive anti-retroviral therapy to get to an undetectable viral load, while also helping people without the virus prevent transmission. “With HIV, we now have PrEP, pre-exposure prophylaxis. Like prevention for HIV, now there are tactics for COVID, social distancing or isolation or facemasks.” Soon, a vaccine could help create herd immunity and reduce risk for much of the population.
Our nurses are also more aware now of the dangers of caring for people with infectious diseases and basing their concerns on the science of how the virus is transmitted. This is one place where the two crises differ. “I don’t think we had health care workers dying from AIDS because they were taking care of people with HIV infections. Now you see that people taking care of patients with COVID are also dying of COVID,” says Marquez-Bhojani.
Many nurses fear we are forgetting the lessons of HIV, particularly when it comes to protecting health care workers. Without PPE and rapid testing, nurses are at risk: “AIDS made us aware of our vulnerability,” says Wooten. “Nurses will adjust but they should not pay the price.” i TN
REFERENCES
1. Hanlon, C., & Higgins, E. (2020). States Use Race and Ethnicity Data to Identify Disparities and Inform their COVID-19 Responses. National Academy for State Health Policy.
PRACTICING REMOTELY
Texas Nursing, Issue 2, 2020
AS THE COVID-19 PANDEMIC SWEEPS the world, a lot of media attention has been given to the patients admitted with this virus. However, across the United States, patients are still experiencing heart attacks, still need dialysis, and still rely on crucial medications to function. While some providers have had to temporarily close their doors under stay-at-home orders, other providers have been able to continue serving their community and patients with telehealth.
First adopted in the 1960s to monitor the health of astronauts from the ground, telehealth has evolved steadily over the subsequent decades. Until now, wide use of telehealth was limited by lower reimbursement rates for providers, regulatory guidelines that vary state to state, and security concerns. However, with many Texans now unable or unwilling to come into the office, telehealth has quickly become a new norm.
QUICK TRANSITIONS
“It has drastically changed,” says Mia Painter, DNP, APRN, FNP-C, who has been practicing for over ten years at San Marcus Family Medicine. Her organization already had established telehealth services integrated into their electronic health records, so they were able to shift nearly the entire practice to telehealth quickly.
“Prior to COVID-19, we were doing telehealth education for diabetes management. We reduced glucose levels in our patients dramatically, and they enjoyed having access to care without having to come in.”
Staff and providers at her clinic found it easy to transition. In a day, the clinic may see between 24-30 patients per provider with extended business hours to accommodate patient schedules. “We still have one nurse practitioner at the clinic for urgent hands-on evaluations, and we are doing drive-up testing for COVID-19,” Painter says. “Everyone else is doing virtual visits from home. We are trying to keep our patients out of health care facilities to reduce the risk of exposure.”
At a rural family practice clinic in the Texas panhandle, Mary Hazel Brantley, DNP, APRN, FNP-C, says her facility has moved towards more telehealth but are still trying to accommodate patients who request an in-person appointment. “A lot of patients who need follow up are older, so it’s harder for them to install an app or use a smart phone,” she says. “Some patients, especially the younger ones, are more receptive about virtual visits and phone visits.”
At the same time, Brantley has seen some older patients who are leery of seeing providers due to social distancing and exposure in clinics. When telehealth is an option, Brantley and her team may do just a phone call or use FaceTime since HIPAA requirements are currently more lenient. “We don’t have a portal yet. We are trying to find a way to use one platform through the whole clinic.”
Both nurse practitioners say their clinics have made the transition easy for patients by letting them schedule the same way they always do. The nurse or doctor will then give them a call at the appointed time.Miss Brown added the foundation also would underwrite scientific research in the field of nursing and make such findings available in order to "promote the health of the public."
“But I’m not Racist….”
Danica Fulbright Sumpter, PhD, RN
Texas Nursing, Issue 3, 2020
“BUT I’M NOT RACIST….”
Typically, this declaration is followed by a personal anecdote demonstrating that the speaker could not possibly be racist. “I have Black friends... a Black spouse... I was in the military... I have a mixed family”—these and other statements equate proximity with being “not racist.” These anecdotes, provided as proof of not being a racist, demonstrate a very specific idea of what people in this country consider “racist.”
DEFINING RACISM
Traditionally, when Americans discuss racism, we conjure images of the KKK, neo-Nazis, or other individuals perpetrating acts of bigotry, violence, and hatred against Black or other Indigenous people of color (BIPOC). To be sure, this personally mediated racism is harmful and continues to plague our society, as evidenced by smartphone-documented instances of white people calling the police on Black people who are sitting at Starbucks, napping in a common room of their college dormitory, or even birdwatching. However, a more insidious, powerful, and enduring form of racism is institutionalized racism, first discussed by Kwame Touré (Stokely Carmichael) and Charles Hamilton in their 1967 book, Black Power: The Politics of Liberation.
These leaders exposed how racism operates in subtle ways through policies and systems, thereby creating a society that upholds white supremacy by precluding the need for individual perpetrators of racism. Acclaimed public health scholar and physician Camara Phyllis Jones defines institutionalized racism as “differential access to the goods, services, and opportunities of society by race.” This disparate access is normalized, legalized, and manifested as inherited disadvantage that has continued to create worse outcomes for generations of BIPOC.
As institutionalized racism materializes as “inaction in the face of need,” there is no need for an identifiable perpetrator. In other words, we cannot blame an individual for the fact that Black mothers are three to four times more likely to die in and around childbirth than their white (and even less educated) counterparts; that the lifetime odds of being incarcerated are one in 17 for a white man but one in three for a Black man; or that the net wealth of white families is nearly 10 times greater than that of Black families.1,2,3 These data are shocking to those who believed the U.S. entered a post-racial world with the Civil Rights Act of 1964 and solidified such with our first Black president in 2008. Clearly, however, race still matters in this country.
UNDERSTANDING OUTCOMES
Maternal and infant health outcomes demonstrate clear differences unexplained by income and education. With an infant mortality rate of 11.4 (per 1,000 live births), Black infants die at a higher rate than all other infants.4 This rate is more than double that of non-white Hispanic and white infants (4.9 and 5.0 respectively). As nurses, we are trained to promote health, and our traditional response to this type of disparity is to counsel Black mothers to eat more nutritious foods, access prenatal care in a timely manner, and educate themselves so they can avoid risk factors.
While diet, early prenatal care, and maternal education all positively influence birth outcomes, individual-focused interventions fall short, evidenced by ever-widening racial disparities. In fact, even after controlling for education and socioeconomic factors, Black women and infants still remain at higher risk for maternal and infant mortality.5 I, as a PhD-prepared Black woman, am more likely to have my infant die than a white woman who has not finished high school.6
As racial equity consultant Joyce James exhorted School of Nursing faculty, staff, and students during her “Groundwater Analysis” training, nurses must shift from asking “What is wrong with these people?” to “What happened to these people?” Initial historical offenses such prejudicial city plans, including redlining or the placement of waste and other toxin-releasing facilities, continue to plague our state and affect many of the social and structural determinants of health for Black Texans.7 We see this playing out in the disproportionate impact of COVID-19 on Black and brown communities across Texas and the nation.8 Learning history, especially the regional history of the communities we serve, is an important part of our learning and unlearning journey.
Studies have shown that the stress of perceived discrimination and racism can lead to physiological changes that not only influence birth outcomes but other health outcomes such as obesity, cardiovascular health, and hypertension.9,10 In addition to efforts to increase the numbers of health care providers who are BIPOC and efforts to increase access to care such as Medicaid expansion, it is incumbent on us as frontline health care providers to recognize and appreciate the impact that racism—personally mediated and institutionalized—has on the health of the individuals and communities we serve.
JUSTICE AND HEALTH—JOINING A COVID-19 TRIAL
Lev Baesh, RN
Texas Nursing, Issue 1, 2021
IT WASN’T LONG AFTER COVID-19 was discovered, and the Mayor of Austin cancelled SXSW, that I realized we were in trouble. And by “we,” I mean the population of the world.
Having come out as a gay man in 1981—at the beginning of the AIDS epidemic—and remembering the devastation a novel illness wrought on my new community, I thought about how I could participate differently this time than I was able to back in ‘81. Then, I was a college student on my way to law school, after, a rabbi, and now, I’ve added nursing to my education and my roles in the world.
As a child, I learned from my family and my Jewish heritage that all of life was about justice. Our role as human beings was pursuing justice, not simply sitting back and commenting on it, or worse, sitting back and benefitting from an unjust world. During the height of the AIDS epidemic, I volunteered for community organizations in New York City, one of the epicenters for the disease. As a rabbinic student and as a rabbi, I fight alongside Palestinians in Israel and Muslims here in the United States to support justice efforts related to my heritage and religious community. Now I have the privilege of thinking about, and acting on, justice as it relates to local and world health.
Pfizer and Moderna were trialing COVID-19 vaccines in Austin. So, after a conversation with my husband Andrew Martin, also a nurse, we both volunteered to be in the trials. Due to our respective ages, and some minor medical conditions that come with age, we joined two different Phase 3 trials. He is in the Moderna study, and I am with Pfizer.
It was not that opting in for the COVID-19 vaccine trials didn’t scare me. I don’t trust government, or the pharmaceutical industry, to have our best interests at heart. Their greed frightens me, and I know the dollar is a main reason for their existence. I hope that the medical issues that touch us, also touch them. I hope that their humanity rides side by side with their greed. I also know that pursuing justice is not meant to be easy work. If it were, it wouldn’t be at the heart of religious and spiritual teachings from all traditions throughout history.
However, it is not hope that overrides my fear. It is my understanding that justice is so important that overrides my fear and supports my hope.
I chose to be in the study for several reasons. I thought I could be a role model for others. The risk we took would make it possible for others to eventually be protected and for advances in health care to be developed safely and effectively. I also opted in because I know that other people in trials often face the choice to become guinea pigs because there is a not insignificant financial gain from being in a study, especially one that needs a lot of subjects quickly and will directly benefit companies with future proceeds.
As a privileged middle-class white male, I felt that I should be in the trenches with the people who regularly risked their health for my benefit. I decided that I could join them and not take livelihood away from them by contributing the study payments back into the community. My share was used to provide food for people in our neighborhood who are experiencing housing insecurity. There is a sweetness to walking up to someone, asking what they need from a local grocery store, going in, and buying it, always adding extra for them.
I don’t consider myself a martyr or a selfless person, who should be identified as a hero. I consider myself a frightened human being who knows that the goal of a just world, and of world health—the justice issue at hand—is what matters. If I am to imagine my life making a difference, getting a couple of shots in the arm is par for the course.
As nurses, we risk our health every day we go to work. Needle sticks, patient outbursts, airborne diseases, chemical contaminants, and other risks are part of showing up for our shift. I hope, in the end, that my choice to be voluntarily injected with a trial vaccine, is seen simply as one more offering we nurses make for the welfare of our family, friends, communities, and the wider world.
If my participation means one more person acts justly, one more nurse is recognized for the work they do by just showing up, and one more person is protected by a vaccine, then I know, whatever the outcome of the trial, justice was done. TN
Communicating about COVID-19
Kanaka Sathasivan, MPH
Texas Nurses Association Staff
Texas Nursing, Issue 2, 2021
When the COVID-19 pandemic hit in 2020, TNA rapidly pivoted to remote work and launched a comprehensive communication strategy to support nurses, including a dedicated webpage, town halls, podcasts and a COVID-19 Task Force to identify critical issues. TNA staff and members worked to vet information, create educational resources in multiple languages and engage with the media to elevate nurses' voices as expert authorities. This collective effort earned TNA a Platinum Award for Crisis Communications and strengthened the organization's relationship with media outlets.
Questioning the Question
Kanaka Sathasivan, MPH
Texas Nurses Association Staff
Texas Nursing, Issue 4, 2021
SEVERAL YEARS AGO, the Board of Nursing (BON) added a simple question to the licensure renewal form: “In the past five years, have you been diagnosed with or treated for schizophrenia or other psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder or borderline personality disorder, which impaired or does impair your behavior, judgment, or ability to function in school or work?”
While the question was intended to protect public welfare and was considered standard and used by other licensing entities at one time, it reinforced stigma and perpetuated discrimination against certain health conditions.
“It was unfair and frustrating,” recalls Andrea Knott, BSN, RN, CPN. Following the birth of her daughter, Knott experienced postpartum psychosis, which led to a diagnosis of bipolar disorder. She worked carefully with her doctor to find a treatment that worked for her and had been doing fine at work. She was applying for renewal a year after her diagnosis. “At first, I saw the question and thought ‘I get it. I get that they want a letter from my doctor.’”
After she applied to renew her license in July 2019, answering the question honestly, she was stunned to receive a letter from the BON requesting documentation and proof of compliance with the Nursing Practice Act.
THE LETTERS
“I felt like I had done something wrong,” Knott said. “But in reality, there was nothing I could do to control what I went through. The only thing I could control was seeking treatment.”
Knott immediately complied with the request, providing documentation and information including work history and year-end evaluations; a resume; a letter outlining the circumstances of her hospitalization; and a response to the allegations of violating the Nurse Practice act to the BON. She also consulted an attorney who shared stories of other nurses who face similar barriers. Some had to wait months for their license to be reinstated, during which time they could not work.
However, Knott was confident she had done nothing wrong and that legally, there would not be grounds to remove her license.
Then the second letter came. On Aug. 13, 2019, the BON requested even more information. Knott began to ask more questions. She hired an attorney, and with their help put together a response packet that included yearly evaluations from manager and coworkers, letters of reference from community members, family, and her pastor attesting to her character.
“With the help of my doctor, I felt safe and confident to not just be a mom but also a health care provider. The packet included great reviews from my peers—they would be the first people to speak up if they were concerned,” she said. Her peers also reinforced that she was doing the right thing by being honest.
However, the BON’s response was discouraging: “They wanted me to be seen by one of their doctors.”
